National nutrition survey september 17 to october 17 2012 CBS, ICN, MOPH, UNICEF, WFP, WHO

Content Methodology Children’s results Mothers’ results Conclusion Sampling Indicators Survey staff Data management Children’s results Nutritional status Breastfeeding Complementary feeding Mothers’ results Multi-Micronutrient supplementation Feeding practices Conclusion

Survey description Objectives Type of survey Target population: To collect updated information on the nutritional and health status of children and women in DPRK To inform policy makers and program managers on priority sectors and strategies. Type of survey Cross-sectional, stratified, two-stage cluster survey based on the SMART and MICS methodologies Provide estimates for: 10 Provinces (Nampo included in South Pyongan Province) National level estimates derived by weighting the un-weighted Provincial results according to population size Target population: All children aged 0 to 59 months Their mothers aged 15 to 49 years

SMART / MICS SMART: S-Standardized M-Monitoring A-Assessment R-Relief T-Transition Simplified, standardized survey methodology for emergency situations MICS: Multiple Indicator Cluster Survey

Methodology

Sampling The primary sampling unit (PSU) is the Ri/Up/Ku/Dong Random selection by the Central Bureau of Statistics (CBS) among all the Ri/Up/Ku/Dong in each Province with a systematic probability proportional to size (PPS) method Final planned number of children to be assessed was: 840 children for all Provinces but only 440 children for haemoglobin 480 children for Pyongyang for all indicators

Indicators for children Age group (months) Global chronic malnutrition / Stunting 0-59.9 Severe chronic malnutrition / Severe stunting Moderate chronic malnutrition / Moderate stunting Global acute malnutrition (GAM) / Wasting 0-59.9, 6-59.9 Severe acute malnutrition (SAM) / Severe wasting Moderate acute malnutrition (MAM) / Moderate wasting % with MUAC <125mm and % with MUAC <115mm 6-59.9 Prevalence of anaemia % who received Vitamin A in last 6 months Morbidity prevalence (sickness) over 14 previous days Prevalence of diarrhea and Respiratory Tract Infection Exclusive breastfeeding proportion 0-5.9 Timely introduction of solid, semi-solid, soft foods 6-8.9 Minimum dietary diversity 6-23.9 Early initiation of breastfeeding 0-23.9 Continued breastfeeding proportion at 1 year 12-15.9

Measurements of children

Indicators for women Mothers Age group (years) % with MUAC <210mm 15-49.9 % with MUAC <180mm % with MUAC <225mm Prevalence of anaemia in all women Prevalence of anaemia in pregnant women (only national estimate) Proportion of women who received multi-micronutrient supplement during pregnancy 15-49.9 with U2 children Length of multi-micronutrient supplementation Minimum dietary diversity

Measurement of Mothers

Survey staff Total of 60 surveyors 2 teams of 3 surveyors per province 1 team leader, 2 enumerators from CBS and ICN Ri/Dong doctor available to take blood samples for hemoglobin test  Training of trainers (4 days) for CBS and ICN Training of surveyors (6 days) in the 2 weeks previous data collection

Results for children

Chronic malnutrition in children 0-59 months – Stunting (Height for Age) Public Health issue*: Very High Public Health issue: High Public Health issue: Medium * WHO (2000) Public health issue classification

Stunting according to age groups

Acute malnutrition in children 0-59 months – Wasting (Weight for Height) Public Health issue*: Serious Public Health issue: Acceptable * WHO (2000) Public health issue classification Public Health issue: Poor

Acute Malnutrition (wasting) according to age groups

Anemia in children aged 6-59 months and mothers Public Health issue*: Severe Public Health issue: Moderate Public Health issue: Mild Public Health issue: Normal * WHO (2000) Public health issue classification

Anemia in children 6-59 months

Mothers who received multi-micronutrient supplementation during their last pregnancy

Length of multi-micronutrient supplementation during last pregnancy

Infant and Young Child Feeding Practices IYCF indicators Age group 1. Early initiation of breastfeeding 0 to 23.9 months 2. Exclusive breastfeeding under 6 months 0 to 5.9 months 3. Continued breastfeeding at 1 year Continued breastfeeding at 2 years 12 to 14.9 months 20 to 23.9 months 4. Introduction of solid, semi-solid or soft foods 6 to 8 months 5. Minimum dietary diversity 6 to 23.9 months 6. Minimum meal frequency Not assessed 7. Minimum acceptable diet (compilation of 1,2,3,4,5,6) 8. Consumption of iron-rich or iron-fortified food Consumption of vitamin A rich food was also assessed

Feeding practices in children and mothers

Early initiation of breastfeeding (within 1 hour after birth)

Exclusive breastfeeding Exclusive breastfeeding in the 647 children aged 0-5.9 months: 68.9% No difference between boys and girls Actual results for exclusive breastfeeding: Correspond to the DPRK 2004 Nutrition Assessment in which 65.1% of children <6 months were exclusively breastfed Are much lower than the 88.6% reported in MICS 2009 Due to small sample size, comparison of exclusive breastfeeding and breastfeeding up to 1 and 2 years by province and with stunting, wasting and anaemia could not be done Why exclusive and continued breastfeeding are so important ? Exclusive breastfeeding from birth to 5.9 months can prevent up to 13% of children’s death Breastfeeding is exclusive when no fluids including water and no food items are given beside breastmilk Continued breastfeeding up to 1 year or 2 years old has positive impact on children’s death through the prevention of main childhood disease killers which are diarrhoea and pneumonia

Complementary feeding Mix breastfeeding Exclusive BF

Proportion of children 6-23 months and mothers who consumed specific food groups essential for growth and health Food groups consumed by children % children 6-23m who had at least once Food groups consumed by mothers % mothers who had at least once 1 Grains, roots, tubers 89.2% Starchy staples 99.6% 2 Legumes and nuts 28.1% 53.2% 3 Milk, yogurt, cheese 15.8% Milk and milk products 2.4% 4 Meat, fish poultry and liver/organ meats 30.0% Meat and fish 40.4% 5 Eggs 12.6% 7.7% 6 Vitamin A rich fruits and vegetables (pumpkin, carrots, etc.) 38.3% Organ meat 2.2% 7 Other fruits and vegetables 37.4% Dark green leaf vegetables 54.4% 8 Other caloric foods (fats and sweets) 73.9% Other vitamin A rich fruits and vegetables 26.8% 9 Other non-caloric foods (spices, clear soup, water) 86.2% 69.3% 10 Breastmilk 64.6% Others (fats, sugar, water, etc.) 99.5

Number of food groups consumed by children 6-23m and mothers Minimum dietary diversity: 4 food groups / day over the recommended 7 food groups for children or 9 food groups for mothers

Proportion of children 6-23m and mothers who eats at least 4 recommended food groups per day

Iron and vitamin A rich foods consumption in children 6-23 months and mothers Iron-rich food by children Iron-rich food by mothers Liver, kidney, heart, or other organ meats Dark green leafy vegetables Any meat, such as beef, pork, lamb, goat, chicken, or duck Organ meat Fresh or dried fish, shellfish or seafood Meat and fish spinach, broccoli, sea weed and other dark green vegetables Vitamin A rich food by children Vitamin A rich food by mothers Liver, kidney, heart, or other organ meats Dark green leafy vegetables Eggs of all sorts Other vitamin A rich fruits and vegetables Pumpkin, carrots, sweet potatoes, and other vitamin A rich vegetables (yellow or orange inside) Organ meat spinach, broccoli, sea weed and other dark green vegetables Eggs Apricot, peach

Iron and vitamin A rich-food consumption in children 6-23 Iron and vitamin A rich-food consumption in children 6-23.9 months and mothers

Discussion and recommendations

Stunting (chronic malnutrition) and Wasting (acute malnutrition) in absolute numbers Total number of cases of global stunting malnutrition (chronic) Total number of cases of severe stunting malnutrition (chronic) Total number of cases of global acute malnutrition Total number of cases of severe acute malnutrition DPRK 475 868 122 805 68 225 10 234

Undernutrition Stunting (chronic malnutrition) has irreversible impact on the development of children and then also on the Country development: Implementation of interventions directly in the communities while improving the role of the Provincial and County levels is essential Wasting (acute malnutrition) situation does not suggest emergency operations but still impairs child growth during acute episode so it cannot be forgotten The management of acute malnutrition at hospital and community levels need to continue and to be expanded MDG1 partially achieved with the reduction by 50% of the underweight since 1990 Underweight is a mix indicator of stunting and wasting

Infant and Young Child Feeding (IYCF) practices Exclusive breastfeeding practice is good but improvement is necessary to increase its practice up to 6 months Increase of the early initiation of breastfeeding is essential to have more impact on neo-natal mortality Delayed complementary feeding at 6 months and the low food diversity needs to be strongly addressed This has high impact on the development of children (stunting and acute malnutrition)

Anemia High prevalence of anemia in children and women and requires more attention as it has important impact on the outcome of pregnancy and children development Despite similar anemia prevalence, women (74.3%) consume more animal or vegetal iron-rich foods than children (49.5%) Anemia in children could be lowered with: Intensified promotion efforts on the importance of iron-rich food in development Multi-micronutrient supplementation associated with deworming

Mothers’ nutritional status Moderate decrease in undernutrition since MICS 2009 from 25.6% to 23.2% but still a lot of progress to be done The high prevalence of anemia and the low food diversity strengthens the need to: Improve the multi-micronutrients supplementation during pregnancy and in lactating women Improve the iron and folic acid supplementation in pre-pregnant women Actively promote adequate food diversity based on accessible / available food at home Although improvement is needed, the better food diversity in mothers illustrate the possibilities to improve children’s food diversity with accessible / available food groups at household level

Recommendations Enhance the coordination of interventions needed in early life, starting during or even before pregnancy, up to two years old Re-dynamize of the promotion of infant and young child feeding practices for both breastfeeding and complementary feeding Strengthen of the promotion of healthy feeding practices among women mainly during pregnancy and lactation Implement multi-sectoral interventions combining mother’s nutrition, infant and young child feeding, hygiene practices, other nutrition interventions, health, WASH, food security and agriculture

Conclusion The achievement in decreasing underweight over time (MDG 1), as well as stunting (chronic malnutrition) and wasting (acute malnutrition), are due to concerted efforts between the Government, the UN Agencies and others partners in DPRK in addressing the different causes of malnutrition Despite all efforts, malnutrition is still of serious concern and requires continued and strengthened interventions on acute and especially chronic malnutrition in order to have more impact on the underweight prevalence and to ensure a more optimal growth of Korean children

Thank you !